Tony has a strong expertise in the healthcare and managed care/payer arena. He currently manages the workflow of Oncology Business Management, a business trade journal geared towards community oncologists/hematologists.

Differences Identified Between What Medicare Covers and What Patients with Cancer Want

Published: Monday, Sep 15, 2014

Does Medicare coverage for patients with cancer match up to what they actually want covered? There appears to be a mismatch between covered benefits and beneficiary preferences that involves quality of life and financial burden of care, according to a study from Duke University. In the study involving 440 participants, 40 to 50% chose benefits that Medicare does not currently cover, namely, home-based long term care and concurrent palliative care. Participants were undergoing treatment for cancer, had recently been treated for cancer, or were helping to care for a patient with cancer enrolled in Medicare.

“Life span is key, but quality of life is key also,” said Donald H. Taylor Jr, PhD, an associate professor of public policy at the Sanford School of Public Policy at Duke University. “Patients are ready to have a more nuanced conversation” with their oncologists and hematologists, he said. He cautions, however, “not to over-interpret the results. This study is more like an agenda-setting commentary on policy.”

Medicare covers what it defines as “reasonable and necessary care” and its standards have guided what private insurers are willing to pay for as well, according to the authors in the study, published in the Journal of Clinical Oncology.

Participants were given a game board and provided with 50 stickers to allocate between 15 benefit categories, some of which were not covered by Medicare. They also met in small groups to go over educational materials about the Medicare benefit categories. The number of stickers given to each benefit category indicated the level of care the patient or caregiver wanted for that benefit.

Given the constraints—a variety of benefit options, a limited budget (the 50 stickers), and a chance to discuss the choices—around half were not very likely to devote all coverage to curative cancer treatment, said Taylor. These categories were for some level of unrestricted cash, home-based long term care services, or concurrent palliative care, which is beyond the current hospice benefits covered by Medicare.

“We have some evidence that demonstrates that for people who are directly facing death that they have some nuanced understandings of what benefit actually means,” he said.

Almost everyone allocated coverage to cancer itself, usually an intermediate or high level of care, and most also chose primary care and prescription drug coverage, which are covered by Medicare. More than 80% of participants also chose palliative care, home care, and nursing home care. Only 12% chose the maximum amount of cancer care.

The authors conclude that patients and care providers are signaling an interest in expanding benefits that focus on improving quality of life for those with cancer, even if resources are restrained. Although the study “didn’t actually impact patient’s care,” said Taylor, the findings suggest that “we just have to culturally learn how to talk about end-of-life decisions in a better way.”

Source:
Taylor DH, Danis M, Zafar Y, et al. There is a mismatch between the Medicare benefit package and the preferences of patients with cancer and their caregivers. J Clin Oncol. 2014 Aug 25. Epub ahead of print.